Client Information

Please provide your up-to-date contact details. To provide the best communication, it is critical to include your email address and phone number.

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Phone

Home Phone

Work Phone

E-mail

Preferred Contact Method

Mobile Phone
Home Phone
Work Phone
Email

If we are unable to reach you, please provide an alternative emergency contact.

Contact Name

Relationship

Phone Number

How did you hear about us?

By using our platform, you acknowledge and agree that our customer provider partners may send you SMS messages for purposes such as appointment reminders, important updates about your pet, and other relevant communications. Your consent for SMS opt-ins is obtained by the customer provider partners, and you authorize them to send SMS messages to the phone number provided through our Platform. Additionally, the two-way texting feature allows you to respond to these SMS messages, enabling interactive communication with our customer provider partners. If you no longer wish to receive SMS messages from our customer provider partners, you retain the right to discontinue receiving SMS notifications from PetDesk. To opt out, simply send a text message with the word “STOP”. For additional instructions on how to use or deactivate the text notification feature, send a text message with the word “HELP”. Message frequency may vary, and standard message and data rates may apply.

YES, I would like to receive text notifications
NO, I do not wish to receive text notifications

Please Fill in Your Pet's Information

Patient Name

Species

Color(s)

Age

Do you have a second pet?

Yes
No

Please Fill in Your Pet's Information

Patient Name

Do you have a third pet?

Yes
No

Please Fill in Your Pet's Information

Patient Name

Do you have a fourth pet?

Yes
No

Do you have a fifth pet?

Yes
No

Please Fill in Your Pet's Information

Patient Name

Patient History

Primary Reason for Your Visit

Symptoms Your Pet is Exhibiting

Please provide additional details about your pet

Is your pet microchipped?

Yes
No
Not Sure
Please Scan

Microchip #

Does your pet have health insurance?

Yes
No

If so, what company

Most Recent Vet

Other Pets In The Home?

Adopted/Purchased From

Additional details about your pet's current state of health

Any current medications?

Any previous medical problems?

Any known allergies or drug reactions?

Anything else we should know about your pet?

If you have previous medical records available to upload, please provide a PDF, image, or document file. If you only have a physical copy, please bring it to the appointment. 1

Click or drag a file to this area to upload.

I hereby consent and authorize you to receive, prescribe for, treat, or operate upon my animal. You (the Veterinarian) are to use all reasonable precautions against injury, escape, or destruction of the animal(s); however, you (the Veterinarian) will not be held liable or responsible in any manner whatsoever for any circumstance arising from the care, treatment, or safekeeping of the animal described, or otherwise in connection therewith, as it is thoroughly understood that I (the owner/responsible party) assume all risk. After five (5) days from the mailing of written notice to the undersigned (owner/responsible party) at the address below to remove the animal(s), the animal(s) will be considered abandoned and may be disposed of or destroyed, as you (the Veterinarian) deem best. It is further understood that such action does not relieve me (the undersigned owner/responsible party) from paying all costs of your services and the use of your hospital, including, but not limited to, the cost of keeping. After carefully reading the above, I fully understand the terms and conditions stated herein.

Signature

Clear Signature

Today's Date

New Client and New Pet Intake